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Placement of neonatal central venous catheter tips in the right atrium: a practice to be avoided?
  1. Department of Paediatrics and Child Health
  2. Clinical Sciences Building
  3. St James's University Hospital
  4. Leeds LS9 7TF, UK

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Editor—Following the recent media interest in pericardial tamponade complicating the use of percutaneous central venous catheters in neonatal patients, we wish to alert readers to our experience. Our previous policy was to accept right atrial placement of percutaneous central venous catheter tips. This was in line with published recommendations1-3 and is still considered acceptable practice in some units in the United Kingdom, in contrast with practice in the United States.4Between 1993 and 1997, we had five cases of neonatal pericardial tamponade, three of which resulted in death. All were associated with right atrial tip position, accompanied by angulation, curvature, or looping of the line.5 We have now changed our unit policy to avoid placement of catheter tips in the right atrium, and instead place them in the superior or inferior vena cava. In addition, to allow for the possibility of catheter migration,6 we recommend that catheter tips should lie at least 0.5 cm outside the cardiac outline on chest radiograph in small infants, or 1.0 cm outside in larger infants. Although the caval position carries a small risk of thrombosis or hydrothorax,2 ,7 these complications are more benign than pericardial tamponade, which has a mortality of 65%.8 ,9 We recommend that placement of a percutaneous central venous catheter tip in the right atrium should no longer be accepted. In addition, we suggest that catheters that display angulation, curvature, or looping within the right atrium carry a particularly high risk of pericardial tamponade and demand urgent action. Although this issue has been the subject of correspondence in the RCPCH email discussion list, where the consensus was to avoid right atrial tip position, we believe there is a pressing need for a wider debate about current practice in the United Kingdom.